Healthcare Provider Details

I. General information

NPI: 1790422780
Provider Name (Legal Business Name): MARY ROSE MABBAGU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 06/11/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9933 WOODS DR
SKOKIE IL
60077-1049
US

IV. Provider business mailing address

9933 WOODS DR
SKOKIE IL
60077-1049
US

V. Phone/Fax

Practice location:
  • Phone: 847-663-8060
  • Fax:
Mailing address:
  • Phone: 847-663-8060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041444579
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.026004
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: